Abstract
This study aims to assess reproductive health knowledge and services utilization among adolescents from Rwamagana District. A community based cross-sectional study was carried out in Rwamagana district. A sample of 392 adolescent aged 15-19 participated in the study. Simple random sampling was used to select respondents. Data was collected by using a questionnaire adopted from previous studies. Data was checked for completeness, cleaned, coded and entered into excel sheet, and then exported to SPSS version 22.0 for further analysis. Frequencies and percentage was used to summarize descriptive statistics. To determine the association between different factors associated with reproductive health knowledge and services utilization, a logistic regression model was employed. Ethical clearance was obtained from the Ethical committee of Mount Kenya University. It was observed that the majority of adolescents in Rwamagana District knew the sign of maturity. Overall the majority of adolescents 91.8% in Rwamagana District had good knowledge about reproductive health services. The majority of adolescents in Rwamagana District (66.8%) had ever utilized reproductive health services at health facility. It was observed that adolescents who live with their parents were more likely to use reproductive health services compared to those who do not live with parents (aOR=2.161, 95%CI: 1.162-4.021, p=0.015). Moderate reproductive health services utilization was observed among adolescents. There is a need to increase adolescent s awareness on the available services at health facilities.
Author Contributions
Copyright© 2022
Mukandagano Patricie, et al.
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Introduction
According to World Health Organization (WHO), adolescents are people between 10 and 19 years of age. Today there are 1.2 billion adolescents worldwide with nearly 90% of them living in developing countries. Adolescence is characterized by significant physiological, psychological and social changes that put adolescents for high risk sexual and reproductive health (SRH) problems. This has partially been because adolescents were considered to be relatively healthy, without a heavy “burden of disease” Adolescents are not quite capable of understanding complex concepts, or the relationship between behaviors and consequences, or the extent of control they have or can have over health decisions making including that related to sexual and reproductive behavior. This makes them vulnerable to sexual exploitation and high-risk sexual behaviors and reproductive health problems Previous studies demonstrated that the age at marriage for adolescents living in rural areas is quite low compared to their counterpart in urban area. For girls these situations predispose them to teenage pregnancy that may have more immediate effect on their life that any other problem. The changing moral & social values and shift in the standard of societal behavior from conservatism to liberal interaction between both sexes is attributed largely to exposure to the media especially television and movies. Adolescents find themselves sandwiched between a glamorous western influence and a stern conservatism at home, which strictly forbids discussion on sex. This dichotomy aggravates the confusion among adolescents have led to increase in premarital sexual activity, pregnancy among unmarried girls apart from the increasing incidence of abortion & STDs. Early and unprotected sexual activity and misconceptions about HIV/AIDs are prevalent among rural adolescents Adolescent’s sexual and reproductive health knowledge include knowledge about the female menstrual cycle and conception, ways to avoid pregnancy, methods of contraception, correct use of condoms and oral contraceptives, sexually transmitted infections and HIV, means of STIs transmission, ways to avoid STIs and symptoms of STIs. Those are the indicator that used to measure knowledge about SRH A study conducted in Nigeria found that about half (51.0%) of the respondents had ever used SRH services. The same study showed less than 50% of adolescent were knowledgeable about STIs while 52.9% were knowledgeable about how to avoid unwanted pregnancy. Factors related to adolescent sexual and reproductive health knowledge were being male, having regular cell phone and access to internet One of the major causes of the high prevalence of STIs among the adolescent is poor utilization of sexual reproductive health services as well as poor knowledge. In developing countries, 20,000 girls of between 15 and 19 give birth every day, One-third these girls are married before 18 years old. Most of them are poor, less educated and living in rural areas Data from Rwanda’s Ministry of Health indicate that adolescents and young adults comprise the majority of Rwanda’s population. For instance, young adolescents (10-14 years) make up about 17.1%, old adolescents (15-19 years) about 12.4% and young adults comprise 10.7% of the total population while another third of the population (32.1%) is under 10 years. The report showed that adolescents remain neglected group, in the country’s health care model this group is neglected because they are considered comparatively healthy with a low disease burden. Yet the choices adolescent make today affect their health and the health of their families in future, especially the choices related to family planning and STDs. It was reported that Rwandan adolescent lack the ability to negotiate safer sex or to seek the health of family planning services Due to the lack of knowledge and poor utilization of reproductive health services the number of unwanted pregnancies and STDs has been increasing in Rwanda. The number of teenage pregnancies in various parts of the country shows how government and parents need to put in more efforts to contain the issue which leads many young girls to drop out of school. For example, in 2016 some 17,000 young girls most of them under 18 years got pregnancy Teenage pregnancy has been described as a major challenge to Rwanda whose numbers are increasing, especially in the rural areas. Poor rural girls with limited or no access to sexual reproductive health services are at higher risk of becoming pregnant or falling victims to sexually transmitted diseases. On other hand, a report from UNICEF showed that young people in Rwanda remain at risk of contracting HIV virus , this is because a large number of young people in Rwanda, are unaware of the risks associated with HIV and particularly how to prevent against HIV. The same report showed that only 49% of males and 43% of female understand how to use condoms Knowledge and the utilization of reproductive health services are the important components in preventing adolescents from different sexual and reproductive health problems. Limited studies on adolescent knowledge and reproductive services utilization have been conducted in Rwanda. These studies were carried out mainly in urban areas among the general population. Therefore assessing factors affecting reproductive health services utilization within adolescent are very important to improve adolescent reproductive health services utilization and thereby reduce the burden of adolescent disease and disabilities associated with reproductive health.
Results
A total of 392 adolescents aged 15-19 participated in the study. Participants were from 10 sectors of Rwamagana District including fumbwe, Munyaga, Gahengeri, Munyiginya, Musha, Muyumbu, Mwulire, Nyakaliro, Nzige and Rubona. Socio-demographic characteristics of adolescents from 10 Rwamagana Sectors are presented in Socio-demographic characteristics of adolescents from Rwamagana District presented in Regarding the socio-demographic of their family, the majority 54.1% had mothers aged 40-49 years old, nearly a half 182(46.4%) reported that their mother had no formal education, 188(48.0%) were in ubudehe category 2, 202(51.5%) reported that they live with their parents, of those who do not live the parent 162(41.3%) were living with their mothers only. Individual knowledge about reproductive health aspects were assessed by 18 questions. Overall knowledge was also estimated. Findings presented in Concerning the maturity of male to pregnant a girl, 254(64.8%) reported that male could be physically mature to get a girl pregnant, 288(73.5%) reported that male get a girl pregnant during puberty. The majority of respondents 339(86.5) agreed that breast development for a girl as a sign of maturity, 301(76.8) said that appearance of public hair for both girls and boys is a sign of maturation, 233(59.4%) of respondents knew appearance of facial hair development for boys is a sign of maturity. It was observed that the majority of adolescents in Rwamagana District knew the sign of maturity where 82.9%, knew that appearance of menstruation for a girl as a sign of menstruation, 75.3% knew that male voice changes as a sign of maturity, 70.9% knew that body shape changes for both girls and boys is a sign of maturity and 79.6% knew that increase of testicular size, acne as sign of maturity. In terms of knowledge about the ways of preventing unwanted pregnancy, the majority of respondents 93.9% knew that consistent and proper use of condom, 76.5% knew that use of oral contraceptive pills, 88.5% knew that use of injectable contraceptive should be used to prevent unwanted pregnancy. Regarding the symptoms of STIs, only 34.9% knew that pain during urination can be STI symptoms, the majority 80.6% knew that pain during sexual intercourse is STI sign. For HIV transmission route, the majority 94.6% knew that HIV can be transmitted during unprotected sex, 82.9% knew that HIV can be transmitted through the sharing sharps. Adolescents were aware about HIV prevention measures where 386(98.5%) agreed that sexual abstinence during adolescents should prevent adolescent to get HIV, all of respondents knew that consistent and proper use of condom can prevent HIV. The findings presented in The findings presented in Adolescents also mentioned obstacle that limit them to seek for reproductive health service, a total of 332(84.7%) said that reproductive health service are not necessary to them. Lack of knowledge on the reproductive health services available for adolescent (61.5%) was mentioned as barrier to service utilization, 303 (77.7%) said that adolescent look healthy, therefore no need of seeking service. The majority 213(54.3%) of adolescents had discussed with parents about reproductive health topics. The reasons for not discussing reproductive health topics with the parents were mentioned where the majority 158(88.3%) reported that they fear to discuss reproductive health topics with the parents. Cultural restriction (38.4%) was also reported as barrier to discuss reproductive health topics with parents. The majority of adolescents 141(78.8%) reported that parents do not give them time to discuss reproductive health topics, parents are always busy and some parents lack knowledge about reproductive health. Nearly a half 195(49.7%) of adolescent live at 2-4 km from the nearby reproductive health service delivery, 21.4% live at more than 5 km from health facility with adolescent reproductive health services. In terms of walking to health center, 47.7% used 30min to reach nearest health center, 5.6% used more than 2 hours In bivariate analysis religion (p=0.009), occupation (p=0.015), education level (p<0.001), age of mother (p<0.001), living status (p=0.039), and distance from/too nearby RH service delivery (p=0.040) were associated with use of reproductive health services in the last 6 months. Female (53.0%) were more likely to use reproductive health services than males, a half of respondents 50.2% who used reproductive health services in the last 6 months were aged 18-19 years old. Most of adolescent who used reproductive health services in the last 6 months were Protestants, currently in schools and live with their parents. Variables with significant association in bivariate analysis (p-value less than 0.05) were taken to multivariate analysis. The findings presented in Despite no significant association observed, adolescents with no formal education were two times more likely to utilize reproductive health services compared to those with secondary education. Similarly, adolescents with mothers aged 30-39 years were more likely to use reproductive health services. Adolescents who live nearest health facility were 1.5 more likely to use reproductive health services but no significant association observed.
Male
187
47.7
Female
205
52.3
15-17
198
50.5
18-19
194
49.5
Single
367
93.6
Cohabiting
25
6.4
Catholic
140
35.7
Muslim
118
30.1
Protestant
134
34.2
Student
125
31.9
Farmer
50
12.8
Merchant
112
28.6
Unemployed
59
15.1
Housewife
46
11.7
No formal education
106
27.0
Primary
84
21.5
Secondary
202
51.6
In School
232
59.2
Out of school
160
40.8
30-39
88
22.4
40-49
212
54.1
50-59
76
19.4
60+
16
4.1
No formal education
182
46.4
Primary
141
36.0
Secondary
39
9.9
Tertiary
30
7.7
Category 1
43
11.0
Category 2
188
48.0
Category 3
161
41.0
Living status
With parents
202
51.5
With no parents
190
48.5
Mother only
162
41.3
Family member
3
0.8
Other ( partners)
25
6.4
Ever heard that reproductive health services are offered at health center
Yes
212
45.9
No
180
54.1
A girl could become pregnancy at first sexual intercourse
Yes
166
42.3
No
226
57.7
A girl could become pregnancy during puberty
Yes
225
57.4
No
167
42.6
A girl could become pregnancy after puberty
Yes
254
64.8
No
138
35.2
Males could be physically mature to get a girl pregnant
Yes
254
64.8
No
138
35.2
Males get a girl pregnant during puberty
Yes
288
73.5
No
104
26.5
Breast development for a girl is a sign of maturity
Yes
339
86.5
No
53
13.5
Appearance of public hair for both girls and boys is a sign of maturation
Yes
301
76.8
No
91
23.2
Appearance of facial hair development for boys is a sign of maturation
Yes
233
59.4
No
159
40.6
Appearance of menstruation for a girl is a sign of maturity
325
82.9
Male voice changes is a sign of maturity
295
75.3
Body shape changes for both girls and boys is a sign of maturity
278
70.9
Increasing of testicular size, acne and body odor are the signs of maturity
312
79.6
Ways of preventing unwanted pregnancy
Consistent and proper use of condom
368
93.9
use of oral contraceptive pills
300
76.5
use of Injectable contraceptives
347
88.5
use of long-lasting contraceptives
179
45.7
Aware about Sexually transmitted infections ( STIs)
329
83.9
STIs Symptoms
Pain during urination
137
34.9
Pain during sexual intercourse
316
80.6
Route of HIV transmission
Unprotected sexual intercourse
371
94.6
HIV can be got during the first unprotected sexual experience
187
47.7
Transfusion of infected blood
191
48.7
Sharing sharps
325
82.9
During child birth
248
63.3
During breastfeeding
118
30.1
Prevention of HIV
Sexual abstinence
386
98.5
Consistent and proper use of condom
392
100
Avoid transfusion with infected blood
300
76.5
Yes
262
66.8
No
130
33.2
Yes
217
55.5
No
175
55.5
HIV testing and counseling
131
60.4
HIV treatment
11
5.1
STI diagnosis
151
55.5
STI treatment
8
2
Never thought of the services
44
11.2
Services not necessary
332
84.7
Lack of knowledge on the services
241
61.5
Young people are healthy
303
77.7
Yes
213
54.3
No
179
45.5
Not necessary
111
62
Fear of parents
158
88.3
Cultural restriction
151
38.4
Other reasons( parents not give us time, parents are busy, parents lack knowledge about the services
141
78.8
0-1 km
113
28.8
2-4 km
195
49.7
>5km
84
21.4
30 min
187
47.7
One hour
121
30.9
Two hours
62
15.8
>2hours
22
5.6
Yes n(%)
No n(%)
0.758
Male
102(47.0)
85(48.6)
Female
115(53.0)
90(51.4)
0.744
15-17
108(49.8)
90(51.4)
18-19
109(50.2)
85(48.6)
0.727
Single
204(94.0)
163(93.1)
Cohabiting
13(6.0)
12(6.9)
Catholic
63(29.0)
77(44.0)
Muslim
71(32.7)
47(26.9)
Protestant
83(38.2)
51(29.1)
Student
61(28.1)
64(28.1)
Farmer
31(14.3)
19(10.9)
Merchant
75(34.6)
37(21.1)
Unemployed
30(13.8)
29(16.6)
Housewife
20(9.2)
26(14.9)
No formal education
63(29.0)
43(24.6)
Primary
60(27.6)
24(13.7)
Secondary
94(43.3)
108(61.7)
0.051
In School
119(54.8)
113(64.6)
Out of school
98(45.2)
62(35.4)
30-39
60(27.6)
28(16.0)
40-49
100(46.1)
112(64.0)
50-59
51(23.5)
25(14.3)
60+
6(2.8)
10(5.7)
0.204
No formal education
93(42.9)
89(50.9)
Primary
87(40.1)
54(30.9)
Secondary
19(8.8)
20(11.4)
Tertiary
18(8.3)
12(6.9)
0.084
Category 1
19(8.8)
24(13.7)
Category 2
114(52.5)
74(42.3)
Category 3
84(38.5)
77(44.0)
With parents
122(56.2)
80(45.7)
With no parents
95(43.8)
95(54.3)
0-1 km
70(32.3)
43(24.6)
2-4 km
110(50.7)
85(48.6)
>5km
37(17.1)
47(26.9)
Time
0.67
Yes
120(55.3)
93(53.1)
No
97(44.7)
82(46.9)
Catholic
0.447
0.256-0.780
Muslim
0.822
0.474-1.424
0.485
Protestant
Ref.
Student
1.072
0.422-2.721
0.884
Farmer
0.581
0.126-2.673
0.486
Merchant
1.102
0.418-2.907
0.845
Unemployed
0.968
0.394-2.375
0.943
Housewife
Ref.
No formal education
2.551
0.842-7.724
0.098
Primary
4.387
0.911-21.119
0.065
Secondary
Ref.
30-39
2.420
0.693-8.455
0.166
40-49
1.807
0.503-6.483
0.364
50-59
2.170
0.565-8.329
0.259
60+
Ref.
With parents
2.161
1.162-4.021
With no parents
Ref.
0-1 km
1.542
0.846-2.810
0.158
2-4 km
1.454
0.747-2.832
0.271
>5km
Ref.
Discussion
Adolescent s reproductive health knowledge are affected by different controversies including says that adolescents are not ready for sensitive sexual information, comprehensive sexual education promote early sex, reproductive health education makes young people promiscuous, reproductive health education does not fit with our culture or religion, adolescent should not use contraceptive methods and adolescent should abstain from sex until marriage The study found that more than a half of respondents 54.1% were not aware that reproductive health services are offered at health center. A total of 64.8% knew that a girl could become pregnancy after puberty, 73.5% knew that a male could get a girl pregnant during puberty. Adolescents in this study were knowledgeable about the signs of maturity for both girls and boys where 86.5% knew that breast development for a girl is a sign of maturity, 76.8% knew that appearance of public hair for both girls and boys is a sign of maturity, and appearance of menstruation for a girl is a sign of maturity. These findings are consistent with a study conducted in Ethiopia where 53.5% of the adolescents who participated in the study responded that a girl could get pregnant the first time she had sex and the age at which it could occur was mentioned as during puberty. The same study reported that the male counterpart could be mature of physically made a girt pregnant during puberty In contrast, a study conducted in China reported that the majority of adolescents had lower knowledge about fertility issues. The results from the Chinese study revealed that unmarried migrants demonstrated low levels of RH knowledge on pregnancy fertilization (29.4%) and contraception (9.1%). Females participants showed more knowledge about pregnancy, contraception and STDs, but with less knowledge on family planning policy than the male participants. Participants aged 15-19 years old had the least knowledge on pregnancy and family planning policy Regarding the reproductive health utilization, this study found that the majority of adolescents 66.8% have ever utilize reproductive health service, 55.5% responded that they visited reproductive health center in the last 6 months prior to the survey. This study showed that there is a significantly higher RH services utilization rate among rural adolescents when it is compared with the study undertaken in Jimma where 41.1% ever experienced the services In bivariate analysis religion, occupation education level, age of mother and living status were associated with use of reproductive health services (P<0.005). This finding are consistent with that conducted in Ethiopia where in bivariate analysis, the factor found to be significantly associated with reproductive health service utilization were education level and living status. In contrast, the same study found that adolescents age, marital status ; mothers educational status; poor family communication habit on SRH issues; family monthly income; history of sexual intercourse; poor discussion on SRH matters with sexual partner, pears, and health workers; perception of risk towards HIV/AIDS were associated with reproductive health services utilization It was observed that adolescents who live with their parents were more likely to use reproductive health services compared to those who do not live with parents (aOR=2.161, 95%CI: 1.162-4.021, p=0.015). In contrast, a study conducted in Ethiopia found that factors such as age of 16-20 years (AOR = 1.85, 95%CI: 1.17-2.92), mother s educational status (being illiterate (AOR = .33, 95%CI:. 14-.77)), discussion about reproductive health services with their family (AOR = 8.02, 9%CI:5.52-11.66), being Merchant (AOR = 2.7995%CI:1.11-6.96), unemployed (AOR = 2.90, 95%CI:1.19-7.06) or student (AOR:2.38, 95%CI:1. 04-5.42) in occupation, high perceived severity (AOR = 4.05, 95%CI:2.68-6.11), high perceived barriers (AOR = .44, 95%CI:.30-64) were independent predictors of reproductive health services utilization among female adolescents the study area
Conclusion
Majority of the adolescents demonstrated higher knowledge about reproductive health services in the study area. Moderate reproductive health services utilization by adolescents in Rwamagana District was observed. This study indicates that less than 60% of adolescents have visited reproductive health center in the last 6 months despite the availability of the services in the study area. The findings from multivariate analysis showed that adolescents who are affiliated to Catholic Church were less likely to use reproductive health services compared to protestant. It was observed that adolescents who live with their parents were more likely to use reproductive health services compared to those who do not live with parents. Parents need to increase the time they spend with their adolescents at home, and improve the discussion on the issues related to reproductive health. Adolescents are encouraged to visit health centers and youth centers in order to be know the services that are available for them at those centers.